November, 2012

Half-ASTRO

By Michael J. Katin, MD

The 54th Annual Meeting of the American Society for Radiation Oncology has just ended, but will be most remembered for the special guest appearance of a very unlikely weather pattern which significantly disrupted the proceedings.

The meeting started on Sunday, October 28, just as Hurricane Sandy was passing
North Carolina, but being diverted northwest by a high-pressure cold front to its north. On the 29th it lost its "hurricane" status but caused extensive damage as it came ashore near Atlantic City, New Jersey, coincident with the hour for high tide plus the gravitational effect of the full moon. By the 30th it was moving inland but the periphery of the storm was still affecting New York and New England

Massachusetts was spared most of the extreme effects of Sandy, but schools and other
public services were closed in Boston on Monday, October 30, with other scheduling adjustments later that week.

Attendees at ASTRO, who had been waiting to be hit by publication of the 2013 CMS fee schedule anticipated for the first week in November, were instead hit by high winds and driving rain, which interfered with many planned activities. Many social events, including alumni gatherings, were canceled, and the business meeting on October 30 was abbreviated . The meeting concluded on October 31, which also happened to be Halloween .
Even after the weather had improved, the resulting disruption of airline schedules accomplished something that medical oncologists have been trying to do for some time—keep radiation oncologists from seeing patients.

Although most of the individual sessions took place, the raison d'etre of the meeting was severely impacted. The official meeting is, of course, just a mechanism for bringing people together to be solicited by salespersons , establish alignments, and, of course, to talk about each other. Instead, it was necessary for attendees to actually attend some of the meeting sessions but then, instead of properly processing newly-encountered information, to have to spend every intervening moment plotting how to get out of town. It would seem, therefore, appropriate to showcase the most profound discoveries presented at the 54th Annual Meeting.

First, note that there were 413 oral presentations and 2,742 poster presentations, minus seven that were withdrawn. That's a total of 3,148 presentations without even counting Educational Sessions, Presidential Symposia, eContouring Learning Labs, and Keynote Addresses, among others. If each one of them contributed only 0.03% to the eventual cure of cancer, there would be no need for a 55th Annual Meeting.

Out of this cornucopia of scientific knowledge, several contributions deserve special attention. This is not to overlook potential basic science breakthroughs that could eventually change the way we make treatment decisions (3212, "O6-methylguanine DNA Damage Signals Through Nfkb1/p50 to Potentiate DNA Strand Break-Induced Cytotoxicity") Certainly, the most disturbing of all, virtually buried among thousands of other projects, is 3237, from MGH: "Out of Field Cancer Risk in Mice Following Exposure to a Clinical Proton Beam." At the other end of the spectrum are the works that helped to get the total of 3,148 and to enhance CV's and fulfill requirements for academic productivity. Several of these have been selected for special recognition, with no intention of negativity toward any of the authors, considering that each of them had at least one more entry accepted at ASTRO than did I. Out of all the entries for adaptive therapy techniques, meta-analyses, treatment modification devices , and quality of life studies, these demonstrate the ultimate accomplishments of our profession:

CATEGORY 1: It's All About Us

249: " Burnout in Academic Chairs of Radiation Oncology in the United States: The SCAROP Survey." A more critical problem than is encountered by Navy SEALS, policemen, and coal miners.

2836: "Association Between Workload and Errors in Clinical Radiation Oncology." Shockingly, more errors are made by people who are overworked .

3084: "Multidisciplinary Prediction of Survival in Advanced Cancer Patients." Radiation therapists, rather that physicians or nurses, are more accurate in predicting survival in patients receiving palliative treatment. Not a surprise.

2863: "Integration of Tobacco Cessation Services Into a Radiation Oncology Clinic." Nothing more critical for overworked radiation oncology personnel than to address a problem that should have already been dealt with by the primary care physician, medical oncologist, multiple levels of administrators, and millions of dollars of advertising .

Special Recognition: 3097: "Rapid Response Radiation Therapist: An Expanding Role in the Palliative Radiation Oncology Service in Australia ." Description of a rapid response/SWAT team to make up for the slow response of overworked academic radiation oncology chairs and eventually allow replacement of physicians completely.

CATEGORY 2: Innovative Clinical Discoveries

3138: "Effect of Insomnia on Patient's Wellbeing During External Radiation in Outpatient Radiation Oncology Clinic." Insomnia has an inverse relationship with a patient's satisfaction with information received about radiation therapy during the first interaction with physicians. Insomnia decreased after radiation therapy. Conclusions: 1. You don't sleep as well if you don't like what you're told. 2. Radiation therapy cures insomnia.

Special Recognition: 2686: The Dosimetric/Clinical Impact on Parotids of Weight Change During Head-and-Neck IMRT." No relationship, but we're getting a publication out of it. Next: The Dosimetric/Clinical Impact on Parotids of Urinary Frequency During Head-and-Neck IMRT."

2398: "Clinical Assessment of Proton Therapy of Prostate Cancer Patients with Auto Activation PET/CT." In the era of cost containment, we can try breaking the bank by treating prostate cancer with proton beam while assessing the response with two or more autoactivation PET/CT's per patient. .If only Warren Buffet had known he could have had this instead.

Special Recognition: There is a continuous unbroken sequence of poster presentations from 3635 to 3675 devoted to charged particle therapy.

CATEGORY 4: Never Say Never

Never too late: 2500: "Long-term Effects on Quality of Life After Treatment of Localized Prostate Cancer: A Comparison of 4 Different Treatment Modalities." Patients treated at a single center in Sweden from 1988 to 1997 were given EORTC-ZLZ-C30 and EORTC QLQ-PR25 questionnaires between October 2000 and March 2001. Over 11 years ago. I guess they took a really long time filling them out.

Never too few: 2834: Results of a Questionnaire for Diagnosis and Treatment of Brain Radiation Necrosis." 3041 members of ASTRO and SNO (The Society for Neurologic Oncology) received a 20-question survey . The response rate was 266/3041 (8.74%). Might as well write the paper anyway.

Never give up: 2598: "The Importance of Overall Treatment Time in the Era of Concurrent Chemoradiation Therapy for Locally Advanced Cervical Cancer." 173 patients with stage IB1-IVA cervical cancer received treatment with definitive chemoradiation between 2000 and 2010 and overall treatment time was correlated to loco-regional control, disease-free survival, and overall survival. Overall treatment time ranged from 43 to 157 days. 157 days!!! That's like going from January 1 to June 5! Mercury orbits the Sun in only 88 days! It only took 116 days to write the Constitution of the United States! P.S. the results are better if you don't take 157 days to get through treatment!

FINAL JEOPARDY CATEGORY: REALLY??

2873: "Radiation Therapy Safety and Tolerance in patients Aged 90+ Years." 25 nonagenerian patients treated with benefit. In Canada. Canada!!!! The role model for cost containment , conservative treatment, and death panels !!!! Who knew??
(Secret: They were in their 60's when they were placed on the list for treatment).